lungs by squeezing a balloon-shaped bag that was attached to the tube in his trachea. Gradually, Daniel's blue skin turned ivory. Ann Marie placed her hands on his head to comfort him. She noticed that his eyes were wide open and unblinking, which upset her. She glanced at Bhatia but, fearful of distract- ing her, didn't say anything. Mian encouraged Ann Marie to talk to Daniel. "It's O.K., Dad," Ann Marie told him. "It's O.K. I'm here." "He's in P.E.A.," Bhatia said, look- ing at a monitor by the bed. "Give him epinephrine and atropine." P.E.A. stands for pulseless electrical activity; Daniel's heart muscle was unable to pump enough blood to generate a pulse. Ann Marie saw a nurse inject the medicines, but she didn't catch the names of the drugs or understand what they were for: to help Daniel's heart contract effectively and move blood faster through his vessels. Instead, she focussed on Danier s face. Each time the intern pressed on Daniel's chest, it seemed to her that his bulging eyes might jump out of his head. "His potassium may be high," Bhatia said. "I want a bolus ofD50, ten units of insulin, with calcium and bicarb." (D50 is a higWy concentrated glucose solution that, in the presence of insulin, will help draw excess potassium from the blood into the cells; calcium helps the heart contract. ) "He has a pulse!" Marill announced. The intern stopped pumping on Dan- ier s chest. "His EKG shows a heart rate of eighty-four," Bhatia told the team. Driscoll noted that the resuscitation at- tempt had been under way for five min- utes when Daniel achieved a stable blood pressure of a hundred and twenty- five over seventy-two. Ann Marie had no idea that Daniel had revived. "I didn't know that his heartbeat had ever returned," she told me later. Daniel sustained the blood pressure for seven minutes. Then Bhatia said, "Oh God, he lost his pulse." "He's got a wide complex with an ac- celerated ventricular escape rhythm," Marill said, looking at the monitor. Once again, Daniel's heart had ceased to beat effectively. A nurse administered more epineph- rine and atropine, and Driscoll made notes on his clipboard. "He hasn't got his pulse back," Marill said. The intern began to sweat as he pressed on Daniel's chest. "Keep pumping," Bhatia said. 'We need an ultrasound." She lowered a wand over Danier s chest which bounced sound waves offhis heart. One cause of pulseless electrical activity is cardiac tamponade, a condition in which fluid accumulates around the heart and com- presses it like a vise, preventing blood from entering the organ. The ultra- sound would detect tamponade and show the strength of any muscular con- tractions. "Does he have any cardiac activity?" Bhatia asked. "N o thing happening," Marill said as he examined the ultrasound image. Daniel's heart muscle was flaccid. "Does anyone have any other thoughts, suggestions, or is there anything else we should do?" Bhatia asked. The doctors and nurses looked at her in silence. "O.K., I guess this is it, then," Bha- tia said. Marill placed his stethoscope over Daniel's chest and listened for breath sounds. There were none. He felt Daniel's neck for a pulse and shook his head. Finally, he shined a pen- light in Daniel's eyes. The pupils didn't respond. Driscoll noted that Daniel was de- clared dead at 2:35 P.M., seventeen min- utes after he arrived at the E.R. Later, Ann Marie said that she thought that Daniel had been dead for a long time before the doctors and nurses stopped their efforts. She was troubled by his fixed stare, which made her feel that Daniel wasn't at peace, and, at her request, Mian asked a nurse to close his lids. Ann Marie told me that Daniel "was the third family member to die in my arms." In 1974, she had been at her fa- ther's bedside at M. G .H. when he died, from complications of advanced diabe- tes, and she had cared for her mother until her death, ten months later, from brain cancer. Ann Marie said that she wasn't sure why she had decided to wit- ness her father-in-Iaws resuscitation. "I think he was probably already dead in the parking lot," she said. "But it's so sad to die alone. I wouldn't want to die alone. I didn't want him to die alone. And when I was in the room I knew the doctors and nurses did everything they could." I asked Ann Marie how she felt about what she had seen in the emer- gency room. "I used to be very sen- o g> 0 c> 0 ð 0 D YJ:l 0 - - -- ':L.........-z...-C> ' ...\.\ \1'-- r__ r ' ð - "./-::- C ó [ /' ------ l J .-! JJ //"..,-:. /V" /""" ... \ ( / ------- -- 0/l,- 2(1:'(, /Z-